Grand Prize Winner

Treatment of Appendicitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?
Amanda Fazzalari, MD, Resident, University of Massachusetts Medical School, Waterbury, CT

Purpose: Previous studies using national datasets have suggested that insurance type drives a disparity in care delivered to emergency surgery patients. We have recently shown that nationally, Medicaid enrolled patients presenting with acute surgical diagnoses, such as appendicitis, are operated on less frequently, have longer times to surgery (TTS), longer length of hospital stay (LOS) and higher rates of in-hospital morbidity.  However, these large databases lack the granularity that smaller single institution series may provide.  The goal of this study is to identify socioeconomic and geographic factors that may account for disparities in care between Medicaid and Non-Medicaid enrollees (excluding Medicare) with acute appendicitis in Central Massachusetts.

Methods: This retrospective cohort study included all adult patients with acute appendicitis at two campuses of an academic medical center in Central Massachusetts between 2010-2017. Baseline sociodemographic and clinical characteristics were compared according to Medicaid enrollment status and univariate and multivariate analyses were performed to assess differences in the frequency of surgery performed, TTS, LOS, and rates of readmission between those with and without Medicaid.

Results: The sample consisted of 1,257 patients, with a mean age of 39.4 years old, 46.4% were female and 135 (10.7%) were enrolled in Medicaid. Medicaid enrollees were significantly younger (33.5 vs 40.1 years, p <0.0001), and more likely to be unmarried (73% vs 48.1%, p<0.0001) or Non-White (54.1% vs 24.4%, p <0.0001) when compared to Non-Medicaid enrollees. Medicaid enrollees were more likely to live in a neighborhood that was closer to the hospital (4.0miles vs 8.3miles, p<0.0009), had a lower median annual income ($40,400.00 vs $67,700.00, p<0.0001), had a lower level of formal education (82.9% vs 91.6% with high school diploma, p<0.0001) and were more likely to belong to a racial/ethnic minority (31.0% vs 17.1%, p<0.0001). Medicaid enrollees were also less likely to have diabetes mellitus, hyperlipidemia, or hypertension. There were no significant differences between the number of Medicaid and Non-Medicaid enrollees who presented with perforated appendicitis (28.9% vs 31.2%, p=0.857) or who underwent laparoscopic appendectomy (96.3% vs 90.7%, p=0.081). While LOS (20h:30m vs 22h:38m, p=0.109), and 30-day readmission rates (17.8% vs 14.5%, p=0.683) were similar between the two groups, there was a significant difference in the median TTS, with Medicaid patients waiting longer, even after adjusting for social and clinical characteristics (6h:47m vs 4h:49m, p<0.001).

Conclusions: This study underscores the importance of local data in understanding delivery of care at the institutional level.  Despite anticipated population differences between patients with and without Medicaid, the treatment of appendicitis did not differ substantially in this single-institution series. While Medicaid enrollees did experience longer TTS, the explanation for this is unclear. Further studies are needed to investigate factors that may account for this difference. These could include disparities in the household support systems, available social support, system issues within the healthcare system, or bias, all potentially leading to delays to surgery among Medicaid enrollees.

Honorable Mention

Treatment of Cardiac Arrhythmia Associated with Subarachnoid Hemorrhage: A Literature and Protocol Review
Caitlin Clark, MD, Resident, Department of Internal Medicine, Case Western Reserve University at MetroHealth, Cleveland Heights, OH

It is widely known that subarachnoid hemorrhage is associated with co-morbid cardiac arrhythmias, which can place the patient at higher risk of mortality in the acute phase of the hemorrhage. Cardiac Arrhythmias are more commonly seen with Hunt Hess Grade 3 and above hemorrhages, due to the presence of blood and blood products in the cisterns. These blood products have been shown to exert deleterious effects upon the hypothalamus, resulting in massive sympathetic discharge leading to cardiac arrhythmia. We aim to discuss the immediate treatments for cardiac arrhythmia associated with subarachnoid hemorrhage, which, if implemented in a timely fashion, can prevent the patient from degenerating into cardiopulmonary arrest. This study consisted of a review of the literature and relevant protocol management for cardiac arrhythmia. There are only a few arrhythmias which are designated “malignant,” and which can lead to the death of the patient if not definitively addressed in a timely manner. These arrhythmias include Monomorphic Ventricular Tachycardia, Polymorphic Ventricular Tachycardia, and Ventricular Fibrillation. All are considered to be non-perfusing rhythms emanating from the ventricles, and are also designated as Irregular Wide QRS-Complex Tachycardias. Any patient in one of these rhythms is not perfusing their brain, adding insult to an already injured brain. All physicians recognize that the routine management of complex cardiac arrhythmias in critically ill patients such as those with subarachnoid hemorrhage will usually require active participation of our Cardiology and Intensivist colleagues. However, it is critically important, and often life-saving, for the neurological surgeon in the intensive care unit to have a thoughtful and pragmatic approach to early identification of these problems, allowing timely intervention to improve patient safety and outcomes.

Endobronchial Ultrasound With Transbronchial Needle Aspiration in The Diagnosis of Thoracic Diseases; A Single Center Experience
Dwight Harris II, BS, Medical Student, University of Kentucky College of Medicine, Manchester, KY

Purpose: Lung cancer remains the leading cause of cancer related mortality in the United States, and obtaining a tissue diagnosis and proper staging is an essential part of treatment plan development. Historically mediastinoscopy has been the gold standard for lung cancer diagnosis and staging, but mediastinoscopy has many limitations including: sensitivity, limited number of lymph node levels that can be sampled, and safety. In 2005, the first Endobronchial ultrasound (EBUS) probe capable of guided transbronchial needle aspiration was introduced. Endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new and less invasive technique being used for lung cancer screening. Many studies have reported that EBUS-TBNA has similar sensitivity and specificity when compared to mediastinoscopy with a significantly lower complication rate. We wanted to determine our institutions experience with EBUS-TBNA, and contribute to the ongoing conversation about the role of EBUS-TBNA vs mediastinoscopy in lung cancer diagnosis and staging.

Methods: With IRB approval we reviewed the last 150 EBUS-TBNA procedures preformed at our institution from August 31, 2017- May 26, 2016 for lung mass evaluation. We selected 10 patients form our institution that had EBUS and 10 that had mediastinoscopy and calculated the cost for both procedures. We also used CPT codes to calculate the 10-year trend in EBUS and mediastinoscopy procedures at our institution.

Results: In total the charts of 150 patients were reviewed. The total number of lymph node stations sampled was 294 with 39 stations read as non-diagnostic. Ninety-eight of the 150 patients had a confirmed diagnosis of malignancy. Thirty-nine patients had a diagnosis other than cancer, and 13 patients had incomplete information or were lost to follow-up. EBUS-TBNA was correct in diagnosing malignancy in 94 of the patients, and EBUS-TBNA or EBUS-TBNA and lab test gave enough information to diagnosis without further invasive testing in 37 of the non-lung cancer patients. Over all the sensitivity, specificity, positive predictive value, and negative predictive values of EBUS where 94.0, 100.0, 100.0 and 91.5 percent respectively. Only three complications were reported intraoperative or at the first follow-up appointment. Two patients suffered minor bleeding, and one suffered major bleeding that resulted in cardiac arrest. Of the 150 patients only eight received mediastinoscopy, and 15 patients received a VATS or thoracotomy. In all eight cases the mediastinoscopy agreed with the results optioned from EBUS-TBNA. Thirteen of the 15 VATS or thoracotomies agreed with the results optioned form EBUS-TBNA. The average net revenue for EBUS-TBNA was 4,136 ± 2,540 (mean ± standard deviation) United States dollars (USD), and the average net revenue for mediastinoscopy was 2,716 ± 1,860 USD.

Conclusions: EBUS-TBNA has a similar sensitivity and specificity to mediastinoscopy, with fewer complications. Compared to mediastinoscopy, EBUS-TBNA is also more cost effective. Because of its reliability, cost effectiveness, and safety, EBUS-TBNA is gradually replacing mediastinoscopy.



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